Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]

Facility

$5.00

Service Code	HCPCS J7515
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP [2032]

Facility

$127.00

Service Code	NDC 64980050448
Hospital Revenue Code	637
Min. Negotiated Rate	$63.50
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$96.52
Rate for Payer: Cash Price	$76.20
Rate for Payer: Devoted Health Medicare	$106.68
Rate for Payer: Hawaii Medical Service Association Medicare	$96.52
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$96.52
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$96.52
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$96.52
Rate for Payer: Ohana Health Plan Medicare	$96.52
Rate for Payer: UnitedHealthcare Medicare	$96.52
Rate for Payer: University Health Alliance Commercial	$92.57

CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP [2032]

Facility

$127.00

Service Code	NDC 64980050448
Hospital Revenue Code	250
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$76.20
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$4.00

Service Code	NDC 70710111001
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

CYPROHEPTADINE 4 MG TABLET [2033]

Facility

$4.00

Service Code	NDC 70710111001
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [96982]

Facility

$27.00

Service Code	HCPCS J9100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$20.52
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association ABD	$0.81
Rate for Payer: Hawaii Medical Service Association Medicare	$20.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.81
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$20.52
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$20.52
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$20.52
Rate for Payer: Ohana Health Plan Medicare	$20.52
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: UnitedHealthcare Medicare	$20.52
Rate for Payer: University Health Alliance Commercial	$19.68

CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [96982]

Facility

$27.00

Service Code	HCPCS J9100
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$14.00

Service Code	NDC 00597036082
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$14.00

Service Code	NDC 00597036082
Hospital Revenue Code	637
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$10.64
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$11.76
Rate for Payer: Hawaii Medical Service Association Medicare	$10.64
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$10.64
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$10.64
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$10.64
Rate for Payer: Ohana Health Plan Medicare	$10.64
Rate for Payer: UnitedHealthcare Medicare	$10.64
Rate for Payer: University Health Alliance Commercial	$10.20

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.00

Service Code	NDC 00597035556
Hospital Revenue Code	637
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$10.64
Rate for Payer: Cash Price	$8.40
Rate for Payer: Devoted Health Medicare	$11.76
Rate for Payer: Hawaii Medical Service Association Medicare	$10.64
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$10.64
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$10.64
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$10.64
Rate for Payer: Ohana Health Plan Medicare	$10.64
Rate for Payer: UnitedHealthcare Medicare	$10.64
Rate for Payer: University Health Alliance Commercial	$10.20

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.00

Service Code	NDC 00597035556
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$8.40
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]

Facility

$38.00

Service Code	HCPCS J9130
Hospital Revenue Code	250
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$22.80
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Kaiser Permanente Commercial	$34.20
Rate for Payer: MDX Hawaii PPO	$36.86

DACARBAZINE 100 MG INTRAVENOUS SOLUTION [2090]

Facility

$38.00

Service Code	HCPCS J9130
Hospital Revenue Code	636
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$36.86
Rate for Payer: AlohaCare Medicaid	$19.00
Rate for Payer: AlohaCare Medicare	$28.88
Rate for Payer: Cash Price	$22.80
Rate for Payer: Cash Price	$22.80
Rate for Payer: Devoted Health Medicare	$31.92
Rate for Payer: Hawaii Medical Service Association ABD	$3.82
Rate for Payer: Hawaii Medical Service Association Medicare	$28.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.82
Rate for Payer: Hawaii Western Management Group Commercial	$36.10
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Humana Medicare	$28.88
Rate for Payer: Kaiser Permanente Commercial	$34.20
Rate for Payer: Kaiser Permanente Medicaid	$19.38
Rate for Payer: Kaiser Permanente Medicare	$28.88
Rate for Payer: MDX Hawaii PPO	$36.86
Rate for Payer: Ohana Health Plan Medicaid	$28.88
Rate for Payer: Ohana Health Plan Medicare	$28.88
Rate for Payer: UnitedHealthcare Medicaid	$22.80
Rate for Payer: UnitedHealthcare Medicare	$28.88
Rate for Payer: University Health Alliance Commercial	$27.70

DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]

Facility

$36.00

Service Code	HCPCS J9130
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

DACARBAZINE 200 MG INTRAVENOUS SOLUTION [2091]

Facility

$36.00

Service Code	HCPCS J9130
Hospital Revenue Code	636
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$27.36
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Hawaii Medical Service Association ABD	$3.82
Rate for Payer: Hawaii Medical Service Association Medicare	$27.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.82
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$27.36
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$27.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$27.36
Rate for Payer: Ohana Health Plan Medicare	$27.36
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: UnitedHealthcare Medicare	$27.36
Rate for Payer: University Health Alliance Commercial	$26.24

DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [126244]

Facility

$2,635.00

Service Code	HCPCS J0875
Hospital Revenue Code	250
Min. Negotiated Rate	$2,239.75
Max. Negotiated Rate	$2,555.95
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Health Management Network Commercial	$2,239.75
Rate for Payer: Kaiser Permanente Commercial	$2,371.50
Rate for Payer: MDX Hawaii PPO	$2,555.95

DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [126244]

Facility

$2,635.00

Service Code	HCPCS J0875
Hospital Revenue Code	636
Min. Negotiated Rate	$15.55
Max. Negotiated Rate	$2,555.95
Rate for Payer: AlohaCare Medicaid	$1,317.50
Rate for Payer: AlohaCare Medicare	$2,002.60
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Devoted Health Medicare	$2,213.40
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Medicare	$2,002.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Western Management Group Commercial	$2,503.25
Rate for Payer: Health Management Network Commercial	$2,239.75
Rate for Payer: Humana Medicare	$2,002.60
Rate for Payer: Kaiser Permanente Commercial	$2,371.50
Rate for Payer: Kaiser Permanente Medicaid	$1,343.85
Rate for Payer: Kaiser Permanente Medicare	$2,002.60
Rate for Payer: MDX Hawaii PPO	$2,555.95
Rate for Payer: Ohana Health Plan Medicaid	$2,002.60
Rate for Payer: Ohana Health Plan Medicare	$2,002.60
Rate for Payer: UnitedHealthcare Medicaid	$1,581.00
Rate for Payer: UnitedHealthcare Medicare	$2,002.60
Rate for Payer: University Health Alliance Commercial	$1,920.65

DALBAVANCIN HCL 500 MG/25ML IV (WET SOLR VIAL) [430126244]

Facility

$3,805.00

Service Code	HCPCS J0875
Hospital Revenue Code	636
Min. Negotiated Rate	$15.55
Max. Negotiated Rate	$3,690.85
Rate for Payer: AlohaCare Medicaid	$1,902.50
Rate for Payer: AlohaCare Medicaid	$3,452.50
Rate for Payer: AlohaCare Medicaid	$1,317.50
Rate for Payer: AlohaCare Medicare	$2,891.80
Rate for Payer: AlohaCare Medicare	$5,247.80
Rate for Payer: AlohaCare Medicare	$2,002.60
Rate for Payer: Cash Price	$2,283.00
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Cash Price	$2,283.00
Rate for Payer: Cash Price	$4,143.00
Rate for Payer: Cash Price	$4,143.00
Rate for Payer: Devoted Health Medicare	$2,213.40
Rate for Payer: Devoted Health Medicare	$3,196.20
Rate for Payer: Devoted Health Medicare	$5,800.20
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Medicare	$2,891.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,002.60
Rate for Payer: Hawaii Medical Service Association Medicare	$5,247.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.55
Rate for Payer: Hawaii Western Management Group Commercial	$6,559.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,503.25
Rate for Payer: Hawaii Western Management Group Commercial	$3,614.75
Rate for Payer: Health Management Network Commercial	$3,234.25
Rate for Payer: Health Management Network Commercial	$2,239.75
Rate for Payer: Health Management Network Commercial	$5,869.25
Rate for Payer: Humana Medicare	$2,002.60
Rate for Payer: Humana Medicare	$2,891.80
Rate for Payer: Humana Medicare	$5,247.80
Rate for Payer: Kaiser Permanente Commercial	$3,424.50
Rate for Payer: Kaiser Permanente Commercial	$2,371.50
Rate for Payer: Kaiser Permanente Commercial	$6,214.50
Rate for Payer: Kaiser Permanente Medicaid	$1,343.85
Rate for Payer: Kaiser Permanente Medicaid	$1,940.55
Rate for Payer: Kaiser Permanente Medicaid	$3,521.55
Rate for Payer: Kaiser Permanente Medicare	$2,002.60
Rate for Payer: Kaiser Permanente Medicare	$2,891.80
Rate for Payer: Kaiser Permanente Medicare	$5,247.80
Rate for Payer: MDX Hawaii PPO	$3,690.85
Rate for Payer: MDX Hawaii PPO	$6,697.85
Rate for Payer: MDX Hawaii PPO	$2,555.95
Rate for Payer: Ohana Health Plan Medicaid	$2,002.60
Rate for Payer: Ohana Health Plan Medicaid	$2,891.80
Rate for Payer: Ohana Health Plan Medicaid	$5,247.80
Rate for Payer: Ohana Health Plan Medicare	$2,891.80
Rate for Payer: Ohana Health Plan Medicare	$2,002.60
Rate for Payer: Ohana Health Plan Medicare	$5,247.80
Rate for Payer: UnitedHealthcare Medicaid	$4,143.00
Rate for Payer: UnitedHealthcare Medicaid	$1,581.00
Rate for Payer: UnitedHealthcare Medicaid	$2,283.00
Rate for Payer: UnitedHealthcare Medicare	$2,891.80
Rate for Payer: UnitedHealthcare Medicare	$5,247.80
Rate for Payer: UnitedHealthcare Medicare	$2,002.60
Rate for Payer: University Health Alliance Commercial	$5,033.05
Rate for Payer: University Health Alliance Commercial	$1,920.65
Rate for Payer: University Health Alliance Commercial	$2,773.46

DALBAVANCIN HCL 500 MG/25ML IV (WET SOLR VIAL) [430126244]

Facility

$2,635.00

Service Code	HCPCS J0875
Hospital Revenue Code	250
Min. Negotiated Rate	$2,239.75
Max. Negotiated Rate	$2,555.95
Rate for Payer: Cash Price	$1,581.00
Rate for Payer: Cash Price	$4,143.00
Rate for Payer: Cash Price	$2,283.00
Rate for Payer: Health Management Network Commercial	$2,239.75
Rate for Payer: Health Management Network Commercial	$5,869.25
Rate for Payer: Health Management Network Commercial	$3,234.25
Rate for Payer: Kaiser Permanente Commercial	$3,424.50
Rate for Payer: Kaiser Permanente Commercial	$2,371.50
Rate for Payer: Kaiser Permanente Commercial	$6,214.50
Rate for Payer: MDX Hawaii PPO	$6,697.85
Rate for Payer: MDX Hawaii PPO	$2,555.95
Rate for Payer: MDX Hawaii PPO	$3,690.85

DANTROLENE 250 MG INTRAVENOUS SUSPENSION [126579]

Facility

$4,478.00

Service Code	NDC 42367054032
Hospital Revenue Code	250
Min. Negotiated Rate	$3,806.30
Max. Negotiated Rate	$4,343.66
Rate for Payer: Cash Price	$2,686.80
Rate for Payer: Health Management Network Commercial	$3,806.30
Rate for Payer: Kaiser Permanente Commercial	$4,030.20
Rate for Payer: MDX Hawaii PPO	$4,343.66

DANTROLENE 25 MG CAPSULE [9718]

Facility

$4.00

Service Code	NDC 49884036201
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

DANTROLENE 25 MG CAPSULE [9718]

Facility

$9.00

Service Code	NDC 50268021715
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$6.84
Rate for Payer: Cash Price	$5.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$6.84
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$6.84
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$6.84
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$6.84
Rate for Payer: Ohana Health Plan Medicare	$6.84
Rate for Payer: UnitedHealthcare Medicare	$6.84
Rate for Payer: University Health Alliance Commercial	$6.56

DANTROLENE 25 MG CAPSULE [9718]

Facility

$9.00

Service Code	NDC 50268021715
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

DANTROLENE 25 MG CAPSULE [9718]

Facility

$4.00

Service Code	NDC 49884036201
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

DAPSONE 100 MG TABLET [2131]

Facility

$11.00

Service Code	NDC 64980056603
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

Know your out-of-pocket cost for care.

All Charges